Notes on FRACTURES rgn 8 surgery 3.docx

Notes made easy and simple on nursing and surgical nursing

1. FRACTURES
Definitions;
1.A partial or complete break in the normal
continuity of a bone. The occurrences normally
result in soft tissue injury to some extent
2.A disruption in the integrity of a living bone,
involving injury to the bone marrow, periosteum
and adjacent soft tissues.
Majority of fractures are due to a force greater than
what the body can bear
Causes
1.Direct force: - a bone is subjected to more stress
than it can absorb from an impact with a solid
object. E.g. direct blow as from a baseball bat, or
a crushing force, such as some automobile
accidents).
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2. 2.Twisting force (torsion) - an indirect force may
cause a break in a bone at a location other than
the site of the twisting force. This type of injury
is common in skiing accidents.
3.Muscle contraction (indirect force) fracture,
powerful contraction may cause muscle to wear
away from the bone, often fracturing or avulsing
part of the bone in the process. It may occur
during a grand mal seizure and in soldiers
(grenade thrower`s fracture). The humerus is
fractured as a result of the muscular contractions
in throwing a hand grenade.
4.Pathological fracture: weakened bones from
age or disease easily fracture, often from just a
slight movement.
5.Fatigue or stress fracture: may occur when a
bone has been subjected to repeated stress. It is
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3. commonly associated with sports enthusiasts and
soldiers. The repeated stress of sustained running
or marching may cause stress fractures of the
feet or lower extremities CLASSIFICATION
OF FRACTURES
Fractures can be classified according to the
following;
A.A GREAT AMOUNT OF SOFT TISSUE
DAMAGE
1.A complicated fracture - associated with a
large amount of nerve, blood vessel, and soft
tissue.
2.Uncomplicated fracture- without damage to soft
tissues. The nature and extent of the damage
depends on the type and direction of the force,
causing the fracture.
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4. B.DIRECTION OF THE FRACTURE LINE IN
RELATION TO THE BONE'S AXIS.
1.Linear: A fracture line that runs parallel to the
bone's axis.
2.Longitudinal: A fracture line that runs along the
length of, but not parallel to, the bone's axis.
3.Transverse: A fracture line that runs, across at a
right angle to, the bone's axis.
4.Oblique: A fracture line that slants across the
bone.
5.Spiral: A fracture line that runs across the bone
at an oblique angle and coils or spirals around
the bone.
C.CLASSIFICATION ACCORDING TO THE
CONDITION OF THE BONE
1.Complete: - bone is completely broken or split
apart.
2.Incomplete: not completely split and part of the
bone remains intact.
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5. 3.Displaced: The bone ends are separated at the
fracture line and are completely out of
alignment.
4.Impacted or compressed: bone ends are
wedged or jammed into each other
5.Depressed: A piece of bone is driven inward, as
in a skull fracture.
6.Comminuted: The bone shatters or fragments
into several pieces
7.Greenstick: An incomplete fracture in which the
bone is partially broken and partially bent. It is
similar in appearance to a piece of "green"
wood when broken.
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6. D.Identification by its location on the shaft of a
bone
1.distal,
2.mid-shaft,
3.proximal
E.Identification by the name of the physician
1.Colles' fracture:
2.Pott’s fracture:
Any of the classification terms may be used
together to better describe a particular fracture.
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7. E.g. An open, complicated, complete,
comminuted fracture.
Other associated conditions:
Dislocation: total loss of continuity between
articular surfaces.
Subluxation: partial loss of continuity between
articular surfaces.
Sprain: the tearing or overstretching of
ligaments
Strain: the tearing or overstretching of muscles
or tendon
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8. DISLOCATION
Definition
It is a displaced joint causing loss of contact of the
articulating surfaces.
Joints of the shoulder, elbow, wrist, digits, hips,
knees, ankles, and feet are affected.
Etiology: Congenital abnormality, trauma,
disease of surrounding joint tissue Signs and
symptoms:
1.Deformity around joint
2.Altered length of the extremity
3.Impaired joint mobility
4.Point tenderness or extreme pain
Treatment
Reduction should be performed immediately.
1.Closed reduction -manual traction either under
local or generalized anesthesia.
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9. 2.Open reduction - required to repair ligaments,
use of wire fixation of the joint or for skeletal
traction.
Complications; Tissue damage, and vascular
impairment if reduction is not done immediately.
Nursing intervention
1.Apply ice to relieve pain until reduction is
attempted.
2.Splint the extremity as it lies even.
3.Keep emergency resuscitation equipment nearby
when client receives IV morphine sulfate or
diazepam during reduction of dislocation
4.Immobilize joint.
PRESENTATIONS OR FRACTURE SIGNS
AND SYMPTOMS
Specific signs and symptoms will vary according to
the type and location of the fracture.
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10. Pain
Shorting of the bone
Loss of function
Muscles spasm: this will intensify the pain.
Swelling
Deformity/Abnormal mobility at the fracture
site.
Discoloration/Echymosis
Edema
Tenderness
Local bruising
Impaired sensation/numbness
Crepitation
D. OPEN OR CLOSED FRACTURE.
1.Open (or compound fracture) - there is an open
wound associated with the fracture site.
2.Closed (simple fracture) there is no break in the
skin associated with the fracture.
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11. Diagnostic measures
A break is identified from a combination of
1.The patient's history.
2.A physical examination
3.Radiographic findings.
HEALING OF BONE
a. Bone healing follows an orderly sequence as in
wound healing.
Hemorrhage between and around the bone ends
Blood clot forms Within 24 hours
Invasion by cells that form granulation tissue.
Differentiation and formation or union of fibrous
tissue known as a soft callus.
The soft callus forms a "bridge" between the
broken bone ends.
Growth of Bone-forming cells within the soft
callus and the soft callus is gradually formed
into a hard callus (ossification).
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12. A firm bony union between the broken ends of
the bone.
Factors influencing fracture healing;
1.Poor realignment
2.Inefficient immobilization
3.Age and physical condition of the patient,
4.Dietary deficiencies
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13. 5.The type of fracture, location, and the adequacy
of the blood supply to the affected area.
6.Infection- will severely handicap healing or
prevent it altogether.
Systemic Factors Affecting Fracture Healing
1.Age
2.Nutrition:
3.Systemic Diseases
4.Hormones
Local Factors Affecting Fracture Healing
1.l. Type of bone:
2.Degree of trauma
3.Vascular Injury
4.Degree of Immobilization
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14. 5.Intra-articular fractures 6.Separation of Bone
Ends
7.Infection:
8.Local Pathology:
PRINCIPLES OF FRACTURE
MANAGEMENT
1.Reducti
on,
2.Immobi
lization
3.Rehabilit
ation.
A.Reducti
on.
Process of restoring the bone ends (and any
fractured fragments) into their normal anatomical
positions.
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15. Closed reduction- bone ends are brought in
alignment by manipulation and manual traction.
X-rays are taken to determine the position of the
bones.
Open reduction - surgical opening is made,
allowing the bones to be reduced manually
under direct visualization. Internal fixation
devices will be used to maintain the bone
fragments in reduction.
B.Immobilization.
Immobilization maintains fracture reduction until
healing occurs. Immobilization may be
accomplished by external or internal fixation.
External fixation includes the use of an
orthopedic casts, splinting and continuous
traction.
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16. Internal fixation- devices such as pins, wires,
screws, rods, nails, and plates are used to
immobilize a reduced fracture. They are either
attached to the sides of the bone or inserted
through the bone, to provide internal
immobilization of the bone.
C.Rehabilitation.
It is the process of regaining the normal strength and
function in the affected area.
Specific rehabilitation is based upon, the type of
fracture and the methods of reduction and
immobilization used.
The physician and the physical therapist develop an
individualized rehabilitation plan for each patient.
EXTERNAL IMMOBILIZATION
1. Orthopedic cast-
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17. Materials - plaster of Paris (anhydrous calcium
sulfate), fiberglass and plastic.
Plaster casts dry slowly, and lose strength and
integrity if they become wet.
Fiberglass and plastic casts are light in weight,
dry quickly, and can be immersed in water and
re-dried.
Types of Plaster of Paris (pop)
1.Short leg cast-- extends from below the knee to
the base of the toes.
2.Long leg cast--extends from the upper or
middle thigh to the base of the toes.
3.Short arm cast--extends from below the elbow
to the palm.
4.Thumb spica or gauntlet cast--extends from
below the elbow to the palm and includes the
thumb.
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18. 5.Long arm cast--extends from axilla to palm,
with the elbow normally immobilized at a right
angle.
6.Walking cast--a short or long leg cast with a
rubber or metal walking device attached to the
foot.
7.Body cast--encases the trunk.
8.Shoulder spica cast--a body cast that encases
the trunk, shoulder, and elbow.
9.Hip spica cast--a body cast that encases the
trunk and one or both lower extremities.
Purpose of a cast (POP)
Casts are used for several purposes.
1.To immobilize fractures and hold bone
fragments in reduction
2.To prevent movement in soft tissue injuries.
3.To maintain proper alignment and correct
deformities (E.g. Scoliosis/arthritis).
4.To permit early mobilization.
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19. 5.To immobilize a body part in a species.
6.To provide support and stability for weakened
point.
CAST APPLICATION
a.Assessing the Patient
Assess for discomfort and blood circulation to
the area. Take note of skin pallor, cyanosis and
coldness to, touch, numbness, etc.
Assess the patient's general response- color of
the skin and mucous membranes, blood
pressure, pulse, respirations, and perspiration.
Determine from the patient's chart the body area
to receive the cast and the purpose.
Check the type of cast material used. Make sure
that the correct size of stockinette and cast
material is available.
b.Assemble Equipment
1.Cast material (P.O, P): The material is
supplied as circular bandage of various widths.
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20. The wider width of bandage is used for the
larger body parts.
2.A bucket of water at about 35-40.50C (95-105F)
to moisten the bandage before it is applied.
Some bandages are pre-moistened and do not
require additional water. Check the
manufacturer’s directions.
3.Stockinette. It is frequently supplied in tubular
form and of different sizes.
4.Reinforcing materials -wire mesh, as required
by the physician, to strengthen the cast.
5.Padding for bony prominences or between skin
surfaces. Nonabsorbent cotton wadding is
frequently used.
6.Plastic-covered pillows to support the injured
part, if necessary
7.Drape to protect the patient and any clothes or
bedclothes from excess cast material and moist
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21. PATIENT PREPARATION
Explain the technique to the patient.
Let understands that the cast will feel heavy and
wet after it is applied
Let the patient know that the cast usually takes
24 to 48 hours to dry completely.
Inform the patient that he may feel warmth
during the application because the cast material
is moistened in warm water.
Make sure that the patient knows if pain is to be
anticipated.
Patients need to know that a cast will change
their balance and ability to move.
Patients need to know that until a cast is dry
little weight is placed on it, because only when
dry it becomes hard and inflexible.
Assisting in cast
application
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22. Provide
Privacy.
Assist the patient to a comfortable sitting or
lying position,
Support the part to receive the cast.
Wash the skin area and dry it thoroughly if there
is no open wound, dry and powder.
Clothing on the body area is removed before the
cast is applied.
Provide padding for bony prominences and
between skin surfaces.
Provide the stockinette of the correct size.
Fit seems appropriate, provide a long strip of
gauze bandage to be placed under the
stockinette.
Care of the patient with a newly applied cast
The primary concern is to prevent complications.
a.Expose a newly applied cast to air circulation.
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23. b.Handle a wet cast carefully to prevent it from
being damaged. It takes 24-48 hours for a cast to
become dry and hard.
c.Handle the cast by lifting and supporting it on a
pillow or with the palms of the hands. Never use
fingers as they will leave indentations, which
cause pressure areas within the cast.
d.Provide plastic covered pillows to support the
cast along its entire length.
e.Review the patient's clinical record as to why
the cast has been applied.
f.Instruct the patient on care of the cast that is wet
and after it is dry.
g.After a cast has cooled and begins to harden,
elevate the casted extremity to reduce swelling
h.supports the elevated cast along its entire length,
on an inclined plane, with the distal joints higher
than the proximal joints.
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24. i.Carry out the following observations;
1.Check the skin temperature of the injured
extremity for coldness.
2.Check and compare the pulses. They should
be equal.
3.Check for complaints of numbness, tingling,
burning, swelling, pain, pressure, or inability
to move the fingers or toes.
4.Report presence of the above signs and
symptoms IMMEDIATELY to avoid
possible tissue necrosis; these findings
indicate possible ischemia.
5.Observe all edges of the cast for any areas that
put pressure on the skin.
6.Observe the extremity encased in plaster for
circulatory impairment hourly during the first
24 to 48 hours, then every 4 hours by
comparing fingers or toes of the casted
extremity with the uninvolved extremity.
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25. j.Perform the blanching (capiIlary refill) test.
1.The nailbeds of the fingers or toe compressed
lightly and released to check how quickly the
color returns.
2.Failure to blanch, or a blue tinge, indicates
impaired venous circulation and congestion of
tissues.
3.Failure of color to return, or cold, pale fingers
or toes suggests impaired arterial circulation.
4.In either case report finding
IMMEDIATELY . Do not wait. Permanent
damage can result from impaired circulation
caused by cast pressure
GENERAL NURSING MANAGEMENT OF
THE PATIENT WITH A CAST
1.Check the edges of the cast and all skin areas
pressure areas. If there are signs of edema or
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26. circulatory impairment, notify the charge nurse
or physician immediately.
2.Slip your fingers under the cast edges to detect
any plaster crumbs or other foreign material.
Move the skin back and forth gently to stimulate
circulation.
3.Smell the cast to detect odors indicating tissue
damage. A musty or moldy odor at the surface
of the cast may be the first indication that
necrosis from pressure has developed
underneath.
4.Check the integrity of the cast by looking for
cracks, breaks, and soft spots.
Access for complications.
1.Assess circulation by performing the test and
comparing the skin temperature and blanching
reaction of the affected limb to that of the
unaffected limb.
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27. 2.Assess the presence of sensation in the affected
limb by touching exposed areas of skin and
instructing the patient to describe what he felt.
3.Assess the motor ability of the affected limb by
having the patient wiggle his fingers or toes.
Patient education.
Instruct the patient to;
Avoid resting cast on hard surfaces or sharp
edges that may dent the cast and cause Pressure
areas.
Never use a coat hanger or other foreign object
to 'scratch" inside the cast. This may cause skin
damage and infection.
Report any danger signs to the nursing staff
immediately; Danger signs include pale, cold
fingers or toes, tingling, numbness, increased
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28. pain, pressure spots, odor, or feeling that the cast
has become too tight.
Report any damage to the cast such as cracks,
breaks, or soft spots.
Never attempt to remove or alter the cast.
Patients immobilized in bed with large body
casts need to learn ways to turn and to move
safely with the use of a trapeze, side rails, etc.
Patients with leg casts may need to learn to walk
effectively with crutches.
Patients with arm casts may need to learn to
apply slings.
All patients need instructions about isometric
exercise for extremities in a cast to prevent
muscle atrophy.
Before discharge from the hospital, patients with
casts will need the following:
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29. Instruction on discharge
Observe for indications of nerve or circulatory
impairment.
Keep the cast dry.
Avoid strenuous activity and follow the
physician`s advice about exercises.
Elevate the arm or leg frequently to prevent
dependent edema.
Move the toes or fingers frequently.
Observe the skin around the cast edges
frequently, and keep it clean and dry.
HOW TO DRY THE CAST
Drying time depends on the temperature, humidity,
size of the cast and method used for drying. The
cast is dry when it no longer appears dull or gray
and no longer feels soft or damp. It should appear
white and shiny and be odorless, hard, and resonant
when tapped.
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30. Measures to enhance drying are:
Expose the cast to the circulating air.
Turn the patient with an extremity cast or body
spica every 2 to 4 hours to ensure even drying.
Use an artificial drier (e.g. a fan or hair drier) if
permitted ➢Tub baths and showers are
contraindicated.
Control of swelling
1.Prevent or alleviate swelling in leg cast by
elevating the extremity above the level of the
heart when lying. After the patient begins to
ambulate he should be encouraged to elevate the
casted extremity when he is seated or resting in
bed.
2.To control swelling with an arm cast
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31. Elevate the extremity on pillows or suspend in
stockinet from an IV pole when the patient is
lying or sitting.
When the patient is ambulatory a sling may be
used for support.
The type of sling required will depend upon
the type of cast applied.
A standard short arm cast or long arm cast can
normally be adequately supported with the
triangular bandage sling.
A sling does not support the arm above heart
level in order to promote drainage and reduce
swelling. The patient should be encouraged to
remove the sling and raise the arm above his
head periodically.
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32. Exercise if permitted
Isometric muscle contractions (contracting the
muscle without moving the part) may be done to
prevent atrophy and maintain muscle strength.
1.If the patient is in a leg cast, have him lie down,
place your hand under his knee and instruct him
to "push down' toward your hand.
2.If the patient has an arm cast, instruct him to
make and release a tight fist.
3.Encourage the patient to wiggle his fingers and
toes frequently.
Supporting the cast
When a large cast, such as a body cast or spice cast,
is applied, the curves of the cast must be supported
in order to prevent sagging and pressure. Support
should be given to the entire cast especially at weak
areas such as the shoulder, hip, and knee. Small
plastic covered pillows should be placed under the
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33. cast in such a manner that there are no gaps between
the pillows.
PERSONAL HYGIENE
a.Bathing: Patient in a large cast will not be able
to bath without assistance. Patient must be
encouraged to do as much for himself as is possible.
Each time the patient is turned to the prone position,
wash the exposed back and buttocks and dry
thoroughly. Apply lotion or powder and gently
massage the skin to stimulate circulation.
b.Elimination: When assisting with a urinal or
bedpan, elevate the back and shoulders slightly
higher than the buttocks to prevent dampening or
soiling of the cast. Pillows may be used for support.
Assist male patients with placement and removal
of the urinal, if necessary.
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34. An emesis basin, slipped in place lengthwise,
may be used by female patient for voiding. The
basin is easier to place and remove than a bed
pan.
When assisting a patient with a bedpan, be
certain that the buttocks are resting on the rim of
the bedpan. The patient's head, shoulders, and
back should be higher than the buttocks if at all
possible.
When a trapeze can be used, instruct the patient
to lift straight up in order to avoid friction on the
skin when placing and removing the bedpan.
After using the urinal or bedpan, assist the
patient to clean himself thoroughly, Check cast
edges for soiling or dampness.
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35. CARE AFTER CAST REMOVAL
a.Continue to provide support to joints and
normal body curves.
The muscles will have become weakened from
disuse and, although movement is encouraged,
support is necessary. Use firm pillows to support the
patient while in bed and use elastic bandages or an
arm sling, if necessary, when the patient is up and
about.
b.Avoid vigorous attempts to remove skin
exudates and crusts of dead skin cells, which are
present when a cast has been in place for several
weeks. Gentle soaking and applications of oil to
soften the skin and loosen crusts may be
recommended.
c.After the cast is removed, the physician or
physical therapist may prescribe exercises to
increase strength. If the patient has been doing
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36. isometric muscle contractions, he will not have
to ''re-learn" to contract his muscles and will
progress more rapidly through rehabilitation.
Atrophy of the part may be noticed, but this
should gradually disappear with the return of
muscle function.
Swelling may develop for a while, but decreases
with improved muscle tone and circulation as the
patient becomes more active
TRACTION
PRINCIPLES OF EFFECTIVE TRACTION
Whenever traction is applied, counter traction must
be used to achieve effective traction.
Counter traction is the force acting in the opposite
direction. Usually, the patient’s body weight and
bed position adjustments supply the needed counter
traction. Additional counter traction may be
achieved by elevating the head or foot end of the
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37. bed. Counter traction prevents the patient from been
dragged into the traction pull direction. Muscle
spasms could not be overcome and all benefits of
traction would not come to position.
The forces involved in traction are based on
Newton`s third law of motion, which states that;
''every action there has to be an equal, and
opposite reaction''
The following are additional principles to follow
when caring for the patient in traction:
1.Traction must be continuous to be effective in
reducing and immobilizing fractures.
2.Skeletal traction is never interrupted.
3.Weights are not removed unless intermittent
traction is prescribed.
4.Any factor that might reduce the effective pull
or alter its resultant line of pull must be
eliminated:
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38. 5.The patient must be in good body alignment in
the center of the bed when traction is applied.
6.Ropes must be unobstructed.
7.Weights must hang freely and not rest on the
bed or floor.
8.Knots in the rope or the footplate must not touch
the pulley or the foot of the bed.
USES OF TRACTION
Traction is used:
1.To promote rest/immobilized a reduced fracture,
which restores and maintains alignment
allowing bones and soft tissue to heal.
2.To prevent fracture deformities.
3.To rest inflamed joints and corrects deformities,
overcomes muscle spasms and therefore aids in
relieving pain.
4.To reduces sub luxations or dislocations of joint.
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39. 5.To help regain the normal length and alignment
of an injured extremity.
6.Finally, to promote movement and exercise.
FORMS OF THE TRACTION
There are several types of traction.
1.Straight or running traction applies the pulling
force in a straight line with the body part resting
on the bed. Buck’s extension traction is an
example of straight traction.
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40. 2.Balanced suspension traction supports the
affected extremity off the bed and allowsfor
some patient movement without disruption of
the line of pull.
TYPES OF TRACTION
1.SKIN TRACTION: Traction may be applied to
the skin
2.SKELETAL TRACTION: Traction applied
directly to the bone
a.A significant problem with skeletal traction is
potential for infection, which could develop in
or around the insertion site. The site must be
inspected daily for drainage and odour. Daily
cleaning and dressing changes may be
prescribed
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41. Factors that affect the planning of basic nursing
care for that patient.
The insertion of pins, wires, or tongs is often done
in the operating room under anaesthesia. Assist the
physician or the orthopedic technician with
positioning of the patient and the arrangement of the
traction apparatus.
Patient will require individualized treatment.
Traction procedures are modified for the
requirements of each patient.
Nursing personnel should understand the nature of
the traction in use and the patient movement that is
permissible while still maintaining the desired of
traction pull.
Cervical skeletal traction
Crutchfield or Vinke tongs are used for skeletal
traction in the treatment of fractures of the cervical
spine. The tong points are inserted in the parietal
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42. area of the skull (just in the out layers of the bone)
and the tong is then attached to the pulling device.
The procedures may be done under local anesthesia
in the operating room or on the ward.
Skeletal traction for the femur
The combination of skeletal traction and balanced
suspension is widely used for the treatment of
fractures of the femoral shaft.
This method of treatment provides considerable
freedom of movement while maintaining efficient
traction on the injured limb.
The Thomas leg splint and Pearson attachment
are used to achieve this balanced suspension
traction.
Arm traction
The type of traction used for the upper extremities
will depend upon the location of the fracture and any
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43. associated injuries, and the preference of the
physician.
As with other body parts the affected part may be
immobilized in skin traction or skeletal traction. The
position of the arm in traction may be sidearm or
overhead.
b. Nursing care considerations for the patient
immobilized in arm traction are the same as for any
other immobilized patient. In addition, the nursing
personnel must observethese precautions:
Compare the radial pulse on the affected side
with the pulse on the unaffected side.
Circulatory impairment must be reported
immediately.
Keep the elevated hand in a position of function
at all times, and observe for pressure points at
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44. the wrist. Be sure that only the fingertips extend
from the sling in the overhead traction set-up.
3. SKIN TRACTION
Refers to any traction where the pulling force is
applied to the affected body via the soft tissues.
Skin traction is used to control muscle spasms and
to immobilize an area before surgery. Skin traction
is accomplished by using a weight to pull on
traction tape or on a foam boot attached to the skin.
Because skin traction is applied to the skin the grip
is less secure, limiting the strength of the traction
force. In other words, the amount of weight that can
be used is lesser. The amount of weight applied
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45. must not exceed the tolerance of the skin. No more
than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used
on an extremity. Pelvic traction is usually 4.5 to 9
kg (10 to 20 lb), depending on the weight of the
patient. Types of skin traction used for adults
include Buck’s extension traction (applied to the
lower leg) the cervical head halter (occasionally
used to treat neck pain), and the pelvic belt
(sometimes used to treat back pain).
Skin traction is used for short periods of time most
commonly for the temporary management of femur
fractures and dislocations and to reduce muscle
spasms and pain prior to surgery. The traction
indirectly affects the skin.
Methods; Adhesives and non-adhesive skin
extensions, splints, slings, foam boots, pelvic
slings and cervical halters can be used.
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46. PRIOR TO APPLICATION OF THE SKIN
TRACTION:
Inspect the skin for rashes, abrasions, or signs of
circulatory impairment since the skin must be
healthy in order to tolerate the traction.
Check the physician as to whether the skin
should be shaved.
Shaving is always advisable because of
possibility of skin irritation or subsequent in
growing hair problems.
The extremity should be clean and dry before
anything is applied to it.
Nurses responsibility during procedure
46 | P a g e

47. Assist with the application of the skin traction
and arrangement of the traction apparatus as
directed by the physician.
Understand the nature of the traction and the
patient movement permissible while still
maintaining the desired traction pull.
The basic position of the patient permissible
movement differs according to the type of
traction used and these factors determines the
basic nursing care plan.
TYPES OF EXTERNAL TRACTION/SKIN
TRACTION
1.Buck`s Extension traction (unilateral or
bilateral) is skin traction to the lower leg. The
pull is exerted in one plane when partial or
temporary immobilization is desired. It is used
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48. to immobilize fractures of the proximal femur
before surgical fixation.
2.Bryant`s traction is an adaptation of a bilateral
Buck`s extension. It is used to reduce fractures
or stabilizes hip joints in children weighing less
than 18 kg, since very young children cannot
usually provide sufficient body counter traction
for a Buck`s extension.
3.Slide-Arm traction; it is used to stabilize
fractures of the upper arm or dislocation of the
shoulder and is similar to Buck`s extension
traction but placed on the arm.
4.Russell`s traction; it is a suspension traction in
which Buck`s extension is applied to the limb
(below the knee), and the limb is supported by
means of a sling held in place by a weight
attached to an overhead bar. The knee sling is
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49. elevated sufficiently to provide a 200 angle
between the patient`s hip the bed.
5.Pelvic girdle Traction; it is made of cloth and
may be lined with flannel or quilted fabric. It
provides traction on the pelvis (illiac crest) and
consequently on the spinal column. It is used for
patients with low back pain that is not caused by
spinal fracture but may be caused an
intervertebral disc lesion.
49 | P a g e

50. Potential problems with this type of traction
includes;
Skin irritation or pressure on the illiac crest,
heels, and sacrum.
Discomfort in the lumbar region for patients
who must lie in the supine position with
pillow support placed under the lumbar curve
often provides relief.
Discomfort from extension of the knee. A
small folded towel placed superior or inferior
to the popliteal space allows slight knee
flexion and may relieve this problem.
6.Cervical Head Halter Traction: It is used to
apply traction to the cervical spine for the relief
of muscle spasm and pain caused by an injured
cervical disc (e.g. a whiplash injury) or arthritis.
SKELETAL TRACTION
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51. Skeletal traction is applied directly to the bone. This
method of traction is used occasionally to treat
fractures of the femur, the tibia, and the cervical
spine. The traction is applied directly to the bone by
use of a metal pin or wire (e.g. Steinmann pin,
Kirschner wire) that is inserted through the bone
distal to the fracture, avoiding nerves, blood vessels,
muscles, tendons, and joints. Tongs applied to the
head (e.g. Gardner-Wells or Vinke tongs) are fixed
to the skull to apply traction that immobilizes
cervical fractures.
The orthopedic surgeon applies skeletal traction,
using surgical asepsis. The insertion site is prepared
with a surgical scrub agent such as povidone–iodine
solution. A local anesthetic agent is administered at
the insertion site and periosteum. The surgeon
makes a small skin incision and drills the sterile pin
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52. or wire through the bone. The patient feels pressure
during this procedure and possibly some pain when
the periosteum is penetrated.
After insertion, the pin or wire is attached to the
traction bow or caliper. The ends of the pin or wire
are covered with caps to prevent injury to the
patient or caregivers. The weights are attached to
the pin or wire bow by a rope-and pulley system
that exerts the appropriate amount and direction of
pull for effective traction. Skeletal traction
frequently uses 7 to 12 kg (15 to 25 lb) to achieve
the therapeutic effect.
NURSING MANAGEMENT OF THE PATIENT
IN TRACTION
Assist and encourage to do as much for himself
as is possible within the constraints of his
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53. immobilization. Aid or perform those tasks that
the patient cannot perform.
Assess the patient and traction set-up to
determine the best method for changing the bed
linen.
When assisting with the bedpan or urinal,
provide adequate time for privacy for the
patient.
Encourage the patient to eat a nutritious diet.
Assist the patient to take several deep breaths
each hour to prevent respiratory complications.
Check the extremities for color (pallor,
cyanosis), numbness, oedema, signs of infection
and pain.
Orthopedic patients confined in traction will
need some sort of diversional activity to relieve
boredom and prevent depression.
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54. Determine whether there is bed board on the bed
to provide a firm foundation. this is a policy in
some agencies, while others require a
physician`s order.
When skeletal traction is used, the nurse checks
the traction apparatus to see that the ropes are in
the wheel grooves of the pulleys, that the ropes
are not frayed, that the weights hang freely, and
that the knots in the rope are tied securely.
The nurse assesses the neurovascular status of
the immobilized extremity at least every hour
initially and then every 4 hours.
Asssess the patient regularly for the clinical
signs of hypostatic pneumonia.
Assess the patient regularly for clinical signs of
emboli. Fat emboli may occur as a result of
fracture of long bone such as femur. The
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55. patient`s pulse, and respiration should be
assessed regularly for evidenced of emboli.
with skeletal traction carry out surgical aseptic
technique for care of the pin site.
Nursing diagnosis for a patient in traction
1.Impaired skin integrity
2.Altered tissue perfusion
3.High risk for peripheral dysfunction
4.High risk for constipation
5.Impaired gas exchange
6.Deficient knowledge on condition
7.High risk for injury
FRACTURES OF SPECIFIC SITES OF THE
BODY
A.Fractures of the proximal end of the femur
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56. It is one of the most common injuries to the
musculoskeletal system of the elderly. Their bones
are brittle from osteoporosis, and particularly it is
common with women due to hormonal changes and
its effect on the ability of bone to reabsorb minerals
leading to osteoporosis. They frequently fall; they
have weak quadriceps muscles, transient ischaemic
attacks, anaemia, and cardio vascular disease.
CLASIFICATION
1.Intra-capsular fractures: They are fractures of
the neck of the femur. It occurs in older people
as a result of indirect violence from slight
accidents. The fracture is frequently impacted.
2.Extra-capsular fractures: They are common
with adults and young people; it is due to direct
violence from heavy fall on the greater
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57. trochanter. They are also referred to as fracture
of the trochanteric region.
Extra-capsular fractures heal faster because of
excellent blood supply. In both cases there is
shortening and aversion of the limb. Treatment
1.Temporary traction such as Buck`s extension
may be applied to hold the fracture in alignment
and reduce muscle spasm until the patient’s
condition is stabilized for surgical intervention
2.Surgical treatment consists of open reduction
and internal fixation, or replacement of the
femoral head with prosthesis
(hemiarthroplasty). Replacement is usually
reserved for a fracture that cannot be
satisfactorily reduced or securely nailed.
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58. B.FRACTUREOF THE SHAFT OF THE
FEMUR
Fracture of the shaft of the femur may be due to
indirect violence. Most of these fractures are seen in
young men who have been involved in a vehicle
accident or have fallen from a height.
It is often associated with multiple
trauma problems. Characteristics
1.Deformity of the leg
2.Inability of the patient to move the hip or the
knee
3.Shock
4.Bleeding about 2-3 units of blood may be lost
5.Dislocation of the hip and the knee may be
present.
6.Pain
Anatomically, the fracture ranges from
subtrochanteric region in the proximal third of the
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59. femur through mid-shaft fractures to supracondylar
fractures in the distal third.
Treatment
1.Skeletal traction is used for a while to achieved
separation of the fracture fragments; this can
take about 2 to 3 weeks until callus is seen on
X-ray. Following callus formation, the fracture
is either left on traction until union or internal
fixation is carried out with intramedullary
nailing to act as an internal splint.
Intramedullary nailing is carried out between the
7 to 10 days after the injury. It is removed
between 12 to 18 months later.
2.Besides the intramedullary nailing, a femoral
cast may be applied 2 to 6 weeks after the
fracture.
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60. Signs and symptoms of a fractured hip
Pain
Severe deformity
Impaired circulation
Impaired sensation
Blood loss
C.FRACTURE OF THE TIBIA AND FIBULA
Fracture of the tibia and fibula results from a direct
violence e.g. a violent twisting motion. They often
occur in association with each other. Fracture of the
tibia are prone to compound as the bone is closed to
the skin.
POTT`S FRACTURE (EXTERNAL
ROTATION)
This is a fracture of the fibula about 7cm above the
ankle joint, with tearing of the internal malleolus of
the tibia or tearing of the ankle joint.
Treatment of Pott`s fracture
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61. Treatment is by closed reduction and immobilization
in a long walking cast.
Partial weight bearing is usually prescribed in 7 - 10
days.
The cast is changed to a short leg cast or brace in 3 -
4 weeks which allow for knee motion.
Open or comminuted fractures may be treated with
skeletal fixation with rods, plates, or nails.
NURSING MANAGEMENT OF A PATIENT
WITH A FRACTURE
Nursing care of a patient with a fracture, whether
casted or in traction, is based upon prevention of
complications while healing.
1.Assess the patient general status
When assessing a patient with a
fracture, check the '' 5 P`s''; Pain,
pulse, pallor, paresthesia, and
paralysis.
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62. I.Pain: Determine location and if it is worse or
better?
II.Pulse: Check the peripheral pulses, especially
those distal to the fracture site. Compare all
pulses with those on the unaffected side. Pulses
should be strong and equal.
III.Pallor: Observe the color and temperature of
the skin, especially around the fracture site.
Perform the capillary refill (blanching) test.
IV.Paresthesia: Examine the injured area for
increase or decrease in sensation. Can the
patient detect tactile stimulation such as a blunt
touch or a sharp pin-prick.Does the patient
complain of numbness or tingling.
V.Paralysis: Check the patient`s mobility. Can he
wiggle his toes and fingers? Can he move the
extremities?
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63. 2.Psychological care
3.Observation
4.Diet
5.Exercise
6.Personal hygiene
7.Medication e.g. Antibiotics or sulphonamides,
morphine or aspirin, sedatives
8.Wound care
Complications of fractures
1.Non-Union
Factors that contributes to non-union may include;
General health status of the patient
Age of the patient
Constitutional disorders
Deficiency of blood supply to the part
Excessive traction
Default fixation
2.Mal-union; i.e. union in a bad position causing
deformity. It may not necessary functions apart.
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64. Osteotomy may be performed to correct this
complication.
3.Haemorrhage due to injury or sepsis.
4.Sepsis in compound fractures
5.Paralysis, due to injury to nerve or to muscle
resulting from too tight splinting.
6.Gangrene due to injury to the main artery
supplying that part or due to neglected splint.
7.Pressure sores (decubitus ulcer)
8.Joint stiffness
9.Shorting limb
10.Postural deformities
11.Walkman`s ischaemia contractures; It is due to
extravasation of blood in the muscle that
interferes with venous circulation. The
congested muscle fibre begins to degenerate and
contracture of the fingers begin to occur.
General complications of fractures
Fat Embolism
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65. Renal calculi
Hypostatic Pneumonia
Delirium
Hypovolaemic shock
Avascular necrosis of the bone
Compartment syndrome
Life threatening complications
Pulmonary Embolism
Fat embolism
Gas gangrene
Tetanus
SURGICAL AMPUTATION
Surgical amputation is the process to remove dead or
unhealthy tissue that cannot be treated by other
means. In Many cases, amputation is done as a life
saving measure.
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66. Surgical amputation is a meticulous highly skilled,
plastic and reconstructive surgery. It is done to
relieve symptoms and to facilitate improved
function.
Reasons for amputation includes the following;
1.Trauma: Injuries from combat, explosions, and
other trauma.
2.Thermal injuries: Electrical injuries, frostbite,
and burns.
3.Peripheral vascular disease; compromised
circulation due to vascular disease.
4.Infection; In case of severe infection of the
bone or soft tissue of a limb.E.g.
5.Osteomyelitis and gas gangrene
6.Congenital deformation; to remove a deformed
and useless limb to permit the fitting of a
functional prosthesis.
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67. 7.Tumors: Malignancy that does not respond to
any form of therapy and threatens to metastasize
throughout the bone.
8.Chronic pain: An extremity may be painful
because of a circulatory problem or other
processes and cannot be controlled in any other
way.
9.Elephantoid limb, scrotum or breast.
THE SITE OF AMPUTATION
The exact location is based on several factors.
There is always a strive to preserve as much of the
limb as possible
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68. Considerations;
1.The blood supply available to the remaining
limb.
2.The functional ability of the remaining limb.
3.The fitting of a functional prosthesis.
4.The patient's age and overall physical condition.
5.The patient`s muscle strength.
6.The patient`s ability to learn.
a.sites for amputation of a lower extremity: the
foot, the ankle (Syme amputation),below the
knee (BKA), above the knee (AKA) at the hip
(hip disarticulation), or at the pelvis
(hemipelvectomy).
b.sites for amputation of an upper extremity:
the fingers, at the wrist, below the elbow (BEA),
above the elbow (AEA), and at the shoulder
(shoulder disarticulation).
c.The term disarticulation describes an
amputation performed through a joint.
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69. The shoulder disarticulation, hip disarticulation,
and hemipelvectomy are done only in cases of
extensive injuries, malignancy, or gangrene.
They are disabling and traumatic procedures.
Types of amputation procedure
1.Open, or guillotine amputation -This
technique is used when an active infection is
present. Skin flap is not sutured over end of
residual limb allowing for drainage of infection.
Skin flap is closed at a later date.
2.Closed amputation: This is the most common
technique used. Skin flap is sutured over end of
residual limb, closing site. It is the preferred
method as it usually heals faster and allows the
patient to be fitted for and begin using a
prosthetic device much sooner.
Diagnostic studies:
69 | P a g e

70. These are done to determine level of amputation
1.Arteriography
2.Thermography
3.Transcutaneous ultrasonic Doppler recordings.
4.CT scan
5.Biopsy
6.Oximetry and other patient`s laboratory studies
PRE-OPERATIVE OPERATION OF A
PATIENT FOR AMPUTATION
1.Psychological care
Encourage the patient to talk freely about his
fears and anxiety.
Help the patient to accept the change in
body image that the operation will bring
about
Give opportunity for the patient to ask
questions.
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71. Adopt an open discussion about the patient
what is likely to take place before and after
the operation.
Discuss the rehabilitation programs the
patient can be taken through to maximum
function of the amputated part
Arrange for someone who has had a similar
amputation and has been successfully
rehabilitated to visit the patient.
If allowed, arrange pre-operative counseling
with physical therapist.
If a mobilization aid such as a walker or
crutches is to be used post-operatively, it is
easier to provide instruction in the pre-
operative period
Allow for grieving. It patient will help
patient to be able to re-establish himself
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72. physiologically, become motivated and
resume satisfactory lifestyle.
The patient and family should be made to
know what functional restoration can be
anticipated.
2.Observation:
Take and record TPR/BP, ➢maintain
intake/output.
Assess the part physically and note the
conditions of the skin e.g. Colour, palpable
pulse, temperature, sensation and pain.
Any health problem should be noted and
treated before surgery.
3.Exercise:
Encourage and assist the patient to carry out
active and passive exercises of the
unaffected limbs to prevent loss of muscular
strength.
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73. Assist him to carry out arm and shoulder
strengthening exercise using weightlighting
and pushing ups in order to strengthen the
shoulders and arms muscles.
If the patient is to use walking aids, transfer
exercise should be done, moving patient
from wheelchair to bed and vice versa.
4.Skin preparation: It is done as in any other
surgery.
5.Nutrition
Ensure that patients’ nutritional status is
good unless in emergency.
Correct dehydration by given IV infusions.
Improve the patient`s nutritional status by
encouraging a balanced diet high in vitamins
and minerals and with adequate protein to
enhance wound healing.
Maintain adequate hydration.
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74. 6.Physiological care: Hb level, WBC`s
estimations, Grouping and cross-matching
should be done. Blood should be made available
in case it is needed.
7.Education: Teach the patient crutch walking
first by letting the patient exercise to develop the
arm and shoulder muscles, patient can be taught
to do push up in prone position, flexion and
extension of the arm with weight in the hands.
POST-OPERATIVE NURSING CARE
Post-operative nursing care involves routine nursing
observation, pain control, positioning exercise,
stump conditioning, and patient education. Patient
education should be done in conjunction with all
nursing interventions.
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75. 1.Amputation bed: A divided bed is usually
prepared so that the stump may be watched for
signs of reactionary haemorrhage. Fracture
boards should be placed under the mattress to
provide a firm base for the patient to move.
2.Position:
The patient should lie in a supine position with
the stump resting flat on the bed.
The stump should be left free in bed and
repeated instructions given to the patient to
keep it flat on the mattress. Sand bags are used
to keep the stump in correct position The
patients should be advised against lifting the
stumps on the sandbag for comfort.
Elevated the limb for a period by raising the
foot end of the bed if prescribed.
Depending upon the type of procedure used,
the extremity may be splint, in traction or
75 | P a g e

76. elevated on pillows. Proper positioning will
prevent contractures with all of the involved
muscle.
3.Relief of pain: Severe pain may be due to
excessive pressure on the body prominence or
haematoma.
Reduced pain with oral medication and pain
modifying technique.
Give Narcotic analgesics for the first 48 hours.
Apply heat by placing a light sandbag on the
residual limb to control muscle spasm and
improve the patient level of comfort.
Persistent may be due to haematoma. Later pain
may be due to wound infection
A relaxation therapy or drug therapy including
anticonvulsant agents may be effective.
Serve appropriate prescribed antibiotic
For persistent phantom pain, adopts
psychological method in dealing with it.
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77. 4. Observation:
a.Observe for bleeding.
•Report any blood stain to the surgeon
•Reinforce dressing until bleeding is brought
under control
•Observe for edema, redness, drainage, and
odour
b.Monitor the patient`s vital signs
•Changes in pulse or blood pressure may
indicate haemorrhage under the bulky
dressing.
•A temperature elevation may indicate the
presence of infection.
c.Check the stump dressing regularly.
•Evidence of bloody drainage should be
marked with a pen and time.
•Excessive bleeding should be reported to the
physician.
•Keep a tourniquet at the bedside in case
bleeding occurs, notify the doctor
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78. immediately and stay with the patient until
doctor arrives.
•Check the proximal end of the stump
dressing for swelling.
•Apply dressings to provide compression of
the stump, but avoid too tight dressing
which may cause ischaemia at the stump
end.
d.Observe the patient for phantom pain: Pain
medication may be required for several days
post-operatively. Some patients experienced a
phenomenon known as ''phantom pain'' or
''phantom sensation'' in which they ''feel'' the
lost limb.
Phantom limb pain is treated much differently
from incisional pain.
•Administering beta blockers such as
propranolol (Inderal) may relieve the continual
78 | P a g e

79. dull, burning sensation associated with the
amputated limb.
•Administering antiepileptics such as
gabapentin (Neurontin) or carbamazepine
(Tegretol)
•may relieve sharp, stabbing, and burning
phantom limb pain.
•Some clients may have relief from
antispasmodics and antidepressant medication.
•The nurse should recognize the pain is real
and manage it accordingly.
•Alternative treatment for phantom limb pain
may include nonpharmacological methods
such as massage, heat, biofeedback, or
relaxation therapy.
•Teach the client how to push the residual limb
down toward the bed while supported on a soft
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80. pillow; it helps to reduce phantom limb pain
and prepare the limb for a prosthesis.
e.Fluid and nutritional status.
f.Helping the patient during grieving:
•Encourage family members to express their
feeling of fear, depression, helplessness and
frustration.
•Acknowledge the patient`s feeling and
reality of the loss and help the patient to
accept the situation.
•Encourage the patient and family to express
their feeling concerning the lost part with
the patient. The nurse should encourage the
patient to look at feel and care the residual
limb.
Physical mobility/exercise:
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81. •Encourage and, assist the patient to carry out
prescribed exercises to preserve, the range
of motion in the affected limb and to
strengthen the remaining limbs
•Encouraged and assisted to change position
frequently; carry out transfer exercises and
how to gain balance
•Teach patient how to stand and gain balance,
how to transfer himself safely from bed to
the chair and from wheelchair to toilet seat.
•Teach how to use walking aids such as
sticks; he is first taught how to walk
between parallel bars and then progressively
to walking with two sticks and to walking
with
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82. one stick. Patient is taught push-up exercises
to strengthen the arm muscles for crutch
walking.
•Hyperextension of the residual limb under
the supervision of a therapist is carried out.
Crutch walking is started when stable
balance is achieved by the patient. The
patient is then taught how to climb stairs and
decent.
•Also assist the patient to perform abdominal
and back extensor strengthening exercises to
maintain trunk strength and decrease the
possible risk of back pain.
•The patient is also taught how to use the
wheelchair.
Bed mobility: Regardless of age, each patient
should be taught a safe and efficient manner in
which to roll and when it comes to sitting, adjust
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83. their position. Long rolling, followed side lying to
sitting or supine lying on the elbows to long sitting,
are two acceptable methods that incorporate all the
necessary skills for efficient bed mobility.
Transfers
The patient must learn to transfer himself from the
bed to a chair or wheelchair and then progress to
more advanced transfer skills such as to the toilet,
tub and car. Unilateral amputees are taught single-
limb where the wheelchair is positioned on the
sound-limb side and the patient pivots limb while
maintaining contact with either the bed or chair. In
most cases, it is advised that transfers to both he
sound and involved side be taught since the patient
will frequently be in situations where transfering
sound side will not be possible.
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84. 8.Prevention of physical injury - Advice and
guide the patient against falls due to phantom
limb. The patient forgets momentarily that he has
one leg; he may experience the sensation that his
limb is still present. Always create awareness of
the loss limb. Give advice to patient to avoid the
use of long loose dresses that could untangle with
crutches. Patient should avoid walking on slipping
floors. He should avoid certain exercises such as
running.
9.Patient Education: The patient and his/her
relatives are taught how to inspect the stump for
oedema, redness, drainage, sensation or tiredness.
They are also taught how to care for prosthesis,
how to fix them, and what to do if the prosthesis is
altered. The patient should be taught to;
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85. •Put it on before he/she get out of bed to decrease
limb swelling.
•Wear it all day when wound has healed
completely.
•Inspect it daily.
•Cleaned it daily with a mild soap.
•Not to fix or adjust it.
•To see the prosthetist yearly to check to see if
any changes are needed.
10.Refer the patient to a community or public
health nurse.
The patient should also be educated to avoid the
following in below knees amputation while he is still
in the ward;
•Hanging the stump over the bed.
•Placing pillow under the back-curving spine.
•Resting the stump on cutch handle.
•Lying with the knees flexed.
•Place pillow between thighs.
•Abduction above knee stump.
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86. DRESSING
•The dressing is left until when drains are to be
removed.
•Drains are removed 2 - 4 days following
surgery. Sutures are removed l0 - l2 days for
above the knee amputation and 3 - 4 weeks for
below knee amputation.
•Aseptic dressing is carried out.
•A total contact rigid dressing that protects the
stump from injury by gentle compression of
tissues to decrease edema and promote wound
healing is to be done.
The stump is bandaged
following dressing.
Bandaging is done to;
•Prevent any terminal edema
•Help encourage a healthy venous return
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87. •Help tone up flabby tissue
•Accustom the stump to a constant covering.
•To shape the residual limb in a firm conical
form for the prosthesis.
When the wound is healed, the stump must be
conditioned and shaped for the proper fitting of
prosthesis. A special bandaging technique is used to
shrink and mold the stump to a smooth conical
shape. During the shaping process, the bandage is
worn day and night. It is customarily removed and
reapplied twice daily or as ordered by the physician.
Different methods are employed in wrapping the
bandage but the objective is the same: to provide
equal, firm compression to the stump. A crisscross
or spiral pattern is used to avoid constriction of the
stump and interfering with circulation.
Prevent contractures:
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88. Don't elevate, flexors very strong, flat bed, prone
position, abduction and adductions
Nursing Diagnosis
Pre-operative:
Anxiety,
Fear of pain,
Impaired physical mobility
Self-care deficits
Impaired body image
Post-operative
Risk for injury, haemorrhage, infections,
contractures.
Anxiety,
disturbed Body image
Deficient Knowledge
impaired comfort, pain (actual and phantom
pain)
Potential for disuse syndrome due to pain and
immobility secondary to amputation of the
extremity.
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89. Impaired physical mobility
Complications of amputation
1.Reactional haemorrhagewithin 12 hours: This
is manifested by excessive bleeding when
dressing or through a drain. It may accompany
general signs of blood loss.
2.Secondary haemorrhage at 7 - 10 days. This is
usually associated with infection of the tissue.
3.lschaemia of the stump
4.Infections
5.Amputation limb neuroma: This is a painful
condition in which one of the nerves
6.remaining as a result of the amputation becomes
swollen held in the scar.
7.Phantom pains: The patient may still complain
of pain in the foot or hand which has
8.been amputated.
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90. CONDITIONS OF THE SPINE
KYPHOSIS
Kyphosis can be defined as an over exaggeration of
posterior thoracic curvature of the spine. It is a
progressive spinal disorder that can affect children
or adults. This disorder causes a deformity
described as humpback or hunchback
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91. Kyphotic curves are more commonly found in the
thoracic or thoracolumbar spine, although they can
be cervical.
•This deformity can be in the form of hyperkyphosis
or sharp angular gibbus
INCIDENCE
All age group but found in males than female.
CAUSES
PRIMARY
Postural round back
Schevermann’s disease
Congenital
Neuromuscular disorder
SECONDARY
Due to trauma
conditions like tumours, arthritis and infections.
SIGNS AND SYMPTOMS
Difficulty breathing (in severe cases)
Fatigue
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92. Mild back pain
Round back appearance
Tenderness and stiffness in the spine
CLASSIFICATION
Kyphosis is classified as either
Postural –No anatomical abnormality of the
spine.
Structural-There is abnormality of the spine.
SCOLIOSIS
Scoliosis is a deformity of the spine seen as a lateral
deviation (curvature). A scoliotic bends to the left or
right and can resemble the letter S OR C.
INCIDENCE
Affects males and female but found mostly in
females than males.
TYPES OF SCOLIOSIS
1.CONGENITAL SCOLIOSIS: Caused by a
bone abnormality present at birth.
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93. 2.NEUROMASCULAR SCOLIOSIS: As a
result of abnormal muscles or nerves.
Frequently seen in people with spina bifida or
cerebral palsy or in those with various
conditions that are accompanied by or result in
paralysis.
3.DEGENERATIVE SCOLIOSIS: This may
result from traumatic (from an injury or illness)
bone collapse, previous major back surgery, or
osteoporosis (thinning of the bone).
4.IDIOPATHIC SCOLIOSIS: The most
common type. It has no specific identifiable
cause. There is, however, strong evidence that
idiopathic scoliosis is inherited
SIGNS AND SYMPTOMS
Asymmetry of shoulders, scapulae, and waist
creases.
Prominent of thoracic ribs on forward bend
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94. Back pain(lumbar) .
Shortness of breath.
Gastrointestinal disturbances
LORDOSIS
Lordosis is an excessive inward curve of the lumber
spine. This causes inward curve in the lower back
which is called a swayback.
INCIDENCE
All age groups.
CAUSE
1.Postural deformity
2.Discitis
3.Heavy abdomen during pregnancy (excessive
visceral fat).
4.Obesity
5.Osteoporosis
SIGNS AND SYMPTOMS
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95. Lordosis can be asymptomatic
Poor vertebral posture
Protruded buttocks (major clinical feature)
Back pain that goes down to the legs
Severe neck
DIAGNOSTIC INVESTIGATIONS
Physical examination- neurologic examination
(for numbness, tingling sensation, pain,
weakness) Adams forward bend test is also done
or a scoliometer is used.
MRI (Magnetic resonance imaging)
X-rays
FBC (full blood count)
CT-Scan
Pulmonary function test
Hb
ECG
MANAGEMENT
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96. Management depends on the cause of the disorder.
Early management is especially important to the
adolescent patient. Routine follow-up is essential.
Physiotherapy is done twice weekly to monitor the
progress or correction of the curvature.
Coral stability exercise is done to manage and
rehabilitate.
MANAGEMENT FOR POSTURAL KYPHOSIS
•Physical therapy may be recommended to
strengthen the patient’s paravertebral muscle. Most
importantly the patient is advised to make a
conscious effort to work toward correcting and
maintaining proper posture.
STRUCTURAL KYPHOSIS
•Padded orthoses (a supportive appliance that can be
applied to or around the body in the care/treatment
of physical impairment or disability) can be used to
control pain, but these do not control curve
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97. progression Bracing is the standard treatment to
control curve progression in adolescents
OSTEOMYELITIS
Osteomyelitis is an acute or chronic inflammatory
process of the bone and its structure secondary to
infections with pyogenic organisms.
Incidence: Osteomyelitis affects about two out of
every 10,000. Osteomyelitis is common in children,
and older than 50s are more likely to have the spinal
form of the infection.
Causes: Staphylococcus aureus is the organism
most commonly isolated from all forms of
osteomyelitis. Others include;
Group B streptococci, Escherichia coli,
Streptococcus pyogenes, and Haemophilus influenza
are common.
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98. In some sub populations anaerobes and gram-
negative organisms, including Pseudomonas
aeruginosa, E-coli, and Serratiamarcescens. Risk
factors
1.Chronic illness (diabetes, rheumatoid
arthritis)
2.Long term use of corticosteroid
3.Poorly nourished people
4.Elderly
5.Obesity
6.Impaired immunity
7.Haemodialysis
8.Recent injury
9.After surgery, osteomyelitis may occur due
to introduction of bacteria. Mode of spread
1.Direct bone contamination from bone surgery
(DRIF), open fracture or traumatic injury (e.g.
gunshot wound).
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99. 2.Hematogenous (Bloodborne); Infection from
other sites of infection e.g. tonsils, boils,
infected teeth, upper respiratory infections.
3.Extension of soft tissue in your infection e.eg.
Incisional infections, ulcers
Pathophysiology
The initial response to infection is inflammation,
edema and increased vascularity. After days,
thrombosis with bone necrosis of the blood vessels
occurs in the area resulting in ischaemia due to
increasing tissue and medullary pressure. The
infection extends into the medullary cavity and
under the periosteum. Pus collection confined rigid
bone and it may spread the infection adjacent soft
tissue and joints.
If the infective process is not controlled early, a
bone sheath (if not controlled early), a bone abscess
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100. may develop. Naturally, the abscess may
spontaneously drain, but more often, resulting
abscess cavity has its walls areas of dead tissue as in
any abscess cavity. However, a bone sheath
(the involuntary forms and surrounds the
sequestrum). Although healing appeared to take
place, chronically infected sequestrum remains
prone producing recurring abscess throughout the
life of an individual. This is known as chronic
osteomyelitis.
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101. Signs/Symptoms of osteomyelitis
1.Pain and/or tenderness in the affected area.
2.Swelling and warmth in the infected area.
3.Fever
4.Nausea, secondarily from being ill with infection
5.General discomfort, uneasiness, or ill feeling
6.Drainage of pus through the skin
7.Excessive sweating
8.Chills
9.Lower back pain (if the spine is involved)
10.Swelling of ankles, feet and legs
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102. 11.Changes in gait (walking pattern that is painful,
yielding a limp). Diagnoses
1.Patient`s history
2.Blood tests: complete blood count, which will
show if there is an increased white blood cell
count; and ESR (erythrocyte sedimentation rate).
3.Blood culture.
4.Needle aspiration: During this test, a needle is
used to remove a sample fluid and cells from the
vertebral space, or bony area. It is then sent to
the lab t be evaluated by allowing the infectious
agent grow on media.
5.Biopsy: A biopsy (tissue sample) of the infected
bone may be taken and tested for signs of an
invading organism.
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103. 6.Bone scan: The scan help the doctor detect
these abnormalities in the early stages, when X-
ray findings may only show normal findings.
MANAGEMENT
Full recovery is possible with acute osteomyelitis;
Medical management
The initial goal of therapy is to control and halt the
infective process. Antibiotic therapy depends on the
results of blood and wound cultures because most
often the infection is more than one pathogen. Some
drugs of choice are ciprofloxacin lincomycin.
Supportive measures include
1.Hydration
2.Diet high in protein, zinc and vitamins
3.Correction of anaemia
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104. 4.Immobilization of the affected part to decrease
discomfort and prevent pathological fracture of
the weakened bone.
5.The use of warm wet soaks may be prescribed to
increase circulation. Surgical intervention
1.Needle aspiration or needle biopsy is done
initially
2.Sequestrectomy is done in chronic cases to;
a.establishes the causative organism and
consequently provide the appropriate
therapy.
b.to open the bone abscess by a wide saucer-
shaped incision which permits removal of
dead bone.
c.to transfer healthy tissue, muscle or skin
pedicle grafts into the bone defect.
3.Debridement may be done
4.Incision and drainage is done when there is an
abscess.
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105. Nursing intervention
1.Immobilize the affected part with a splint to
decrease pain and muscle spasm
2.The wound is usually very painful and must be
handled with great care
3.Elevate the affected limb to reduce swelling and
discomfort
4.To improve circulation, warm saline soaks for
20 minutes several times a day may be
prescribed.
5.Restrict physical mobility and avoid stress on
the bone to promote general welbeing.
6.Prescribed medications for antibiotic therapy
such as cephalosporin, aminoglycosides,
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106. penicillin, and tetracycline should be carefully
monitored.
7.Relieve pyrexia
8.Take measures to prevent infections.
Nursing diagnosis
1.impaired body comfort (pain) related to
inflammatory process.
2.Impaired physical mobility related to Pain or
used immobilizing devices. 3.Hyperthermia
related to infection
Complications
1.Bone abscess (pocket of pus)
2.Bone necrosis (bone death)
3.Spread of infection
4.Inflammation of soft tissue (cellulitis)
5.Blood poisoning (septicaemia)
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107. 6.Chronic infection that doesn`t respond well to
treatment.
7.Septic arthritis
8.Impaired growth
9.Skin cancer
10.Non-healing wound
BONE TUMOR
Bone tumor refers to a neoplastic growth of
tissue of the bone. It can either be benign and
malignant abnormal growths found in bones.
Classification
1.Primary bone tumors: Primary bone tumor
divided into benign tumors and cancers.
a.Common benign tumors may be
developmental, traumatic, infections, or
inflammatory in etiology. E.g. osteoma,
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108. aneurysmal bone cyst, and fibrous dysplasia
of bone.
b.Malignant primary bone tumor include
osteosarcoma, Ewing`s sarcoma, malignant
fibrous histiocytoma, and other sarcoma
types.
2.Secondary bone tumors- include metastasic
tumors which have spread from other organs
e.g. the breast, lung, and prostate. They involve
the axial skeleton and the appendicular skeleton.
Tumors which originates in the soft tissues may
also secondarily involve bones through direct
invasion.
Symptoms
The most common symptom is pain. To many
patients it is a painless mass. Some bone tumors
may weaken the structure of the bone, causing
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109. pathological fractures. Fever, chills, night sweats,
and weight loss can occur but less common. These
symptoms are more common after spread of the
tumor to other tissues of the body.
Diagnoses
1.Complete medical history
2.Complete physical examination
3.Plain x-rays. In some cases, if the cancer is
identified very early it may not show up on plain
x-rays.
4.CT scan (CT scan or computed tomography:
This test gives very good detail of bones and is
better able to identify a possible tumor. It also
gives additional information on the size and
location of the tumor.
5.M.R.I (magnetic resonance imaging) - MRI
provides better details of the soft tissues
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110. including muscles, tendons, ligament, nerves,
and blood vessels than a CT scan. This test can
give better detail on whether or not the bone
tumor has spread through the bone and involved
the surrounding soft tissues
6.Biopsy sample of the tumor. This involves
taking a small sample of the tumor that can be
examined in the laboratory to determine what
kind of tumor it is. The biopsy obtained either
through a small needle biopsy or through a
small incision (incisional biopsy)
Treatment
The best treatment is based on the type of bone
cancer, the location of the cancer, how aggressive
the cancer is and whether or not the cancer has
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111. invaded surrounding or distant tissues
(metastasized).
There are three main types of treatment for bone
cancer;
i.Surgery
ii.Chemotherapy
iii.Radiation therapy.
These can be used either individually or combined
with each other.
SURGERY
The goal of the surgery is usually to remove the
entire tumor and the surrounding area of normal
bone. After the tumor has been removed, a
pathologist examines it to determine if their normal
bone is completely surrounding the tumor. If a
portion of the cancer is left behind, it can continue
to grow and spread, requiring further treatment.
Depending on the amount of the bone removed,
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112. bone cement or a bone graft from another part of the
body or from the bone bank will be replaced
children.
CHEMOTHERAPY AND RADIOTHERAPY
chemotherapy and radiotherapy are effective in some
tumors (such as Ewing`s sarcoma) but less so in
others (such as chondrosarcoma)
METHODS OF INTERNAL FIXATION
Internal fixation - holding together the fragments
of a fractured bone without the use of external
appliances. After open reduction, smooth or
threaded pins, Kirschner wires, screws, plates
attached by screws, or medullary nails may be
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113. inserted to stabilize the fragments. Advantages of
that form of immobilization is that, it is;
Secure
Accurate
long-timed alignment is achieved
Disadvantages of internal fixation;
Contraindication may be introduced into the
fracture site.
Circulation may significantly be disrupted by the
device.
The device may further damage adjacent bones,
nerves, or other nearby tissues.
There may be mechanical failure.
Indications:
1.Failure to obtain or maintain fracture reduction.
2.Irreducible fractures
3.Unstable fractures
4.Fractures that unite poorly.
5.Pathological fractures
6.Multiple fractures
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114. TYPES OF INTERNAL FIXATION
1.Lag screwing
2.Plating
3.Intramedullary nailing (Kunstcher nail)
4.Tension Band writing
5.Kuntscher nailing
6.Austin-More`s prosthesis
7.Jewett nail
8.Switch-Peterson nail
9.Steinmann`s pin
10.Ambi nail
11.Ender rod
12.Knowles pin
13.Kirshner`s wire
Complications
1.Infections
2.Non-union
3.Implant failure
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115. 4.Refracture
5.Bleeding
6.Nerve impairment
Factors that may increase the risk of
complications
1.Smoking
2.Heart or lung disease
3.History of blood clots
4.Obesity
5.Infections
6.Diabetes
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